Girl Scouts of Riverland Council
2710 QUARRY ROAD • LA CROSSE, WISCONSIN 54601
PHONE: (608) 784-3693 TOLL FREE: 1-(800)-787-2688
(This form needs to be completed and signed when meeting outside the regular meeting time and place. Example:
Your troop meets on Tuesday nights and you have a field trip on Saturday.)
Group/Troop # __________ is planning:
A day outing/field trip to_________________________________________
An overnight/camping event at ____________________________________
What to bring/wear:______________________________________________________
The leaders/adults in charge: ______________________________Phone _____________________
In case of emergency, or change of plans, they will call you at the number listed below. If you need to
contact the group for emergencies only while they are away, please call __________________________
At ________________________. She/he will have the troop itinerary and emergency numbers.
Parent/ guardian, keep this portion for your information. Return the bottom portion to the leader
(Return even if girl is not attending)
My daughter (full name)_________________________________________has permission to attend the
group outing to ___________________________________on (date)__________________________, we
can be reached by phone at___________________________.
I will make sure she does not attend if she is not feeling well and I will let you know. If her physical
activity is to be limited in any way, or if she has allergies which may affect her it is noted here:
Medication (please complete medication permission on the back of this form)
I give permission for any emergency medical action which may be needed (including x-rays. Our family
doctor’s name is __________________________________, phone_________________________.
Check: I will drive
Valid driver’s license number__________________________
Current auto insurance carrier__________________________
I will chaperone
Fee for outing enclosed/attached
My daughter will not attend this group outing (return even if girl not attending)
Optional: Fill out if this applies for special activities and/or group overnights.
Sleeping bag or bed roll *Flashlight
Pajamas & pillow Change for phone/vending machines
Clothing for 2 days/nights *Insect repellent – no aerosol cans!
Jacket & sweater or sweatshirt Sun screen
Raincoat, hat, boots Backpack & sit upon
Extra shoes Camera – optional
Towel, soap, deodorant Garbage bag for wet items
Toothbrush & toothpaste Activities for quiet/free time (cards, books,
Comb & brush travel games)
Sanitary items (if needed) Other:______________________________
Unbreakable/washable plate, cup
Knife, fork, spoon
*Only needed for troop camping All items should be packed in bedroll or overnight bag.
Extended Trip Itinerary:
PERMISSION FOR ADMINISTERING MEDICATION
The adults in charge of this outing have my permission to administer the following medication to my
Dosage to be given:
Date(s) to be given:
Time(s) to be given: